Reinier B. Beks and David Reetz have dual first authorship.
Over the years, a trend has evolved towards operative treatment of flail chest although evidence is limited. Furthermore, little is known about operative treatment for patients with multiple rib fractures without a flail chest. The aim of this study was to compare rib fixation based on a clinical treatment algorithm with nonoperative treatment for both patients with a flail chest or multiple rib fractures.
All patients with ≥ 3 rib fractures admitted to one of the two contributing hospitals between January 2014 and January 2017 were retrospectively included in this multicenter cohort study. One hospital treated all patients nonoperatively and the other hospital treated patients with rib fixation according to a clinical treatment algorithm. Primary outcome measures were intensive care length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. To control for potential confounding, propensity score matching was applied.
A total of 332 patients were treated according to protocol and available for analysis. The mean age was 56 (SD 17) years old and 257 (77%) patients were male. The overall mean Injury Severity Score was 23 (SD 11) and the average number of rib fractures was 8 (SD 4). There were 92 patients with a flail chest, 37 (40%) had rib fixation and 55 (60%) had non-operative treatment. There were 240 patients with multiple rib fractures, 28 (12%) had rib fixation and 212 (88%) had non-operative treatment. For both patient groups, after propensity score matching, rib fixation was not associated with intensive care unit length of stay (for flail chest patients) nor with hospital length of stay (for multiple rib fracture patients), nor with the secondary outcome measures.
No advantage could be demonstrated for operative fixation of rib fractures. Future studies are needed before rib fixation is embedded or abandoned in clinical practice.
Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48:1040–7. CrossRef
Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37:975–9. CrossRef
Lin FC-F, Li R-Y, Tung Y-W, Jeng K-C, Tsai SC-S. Morbidity, mortality, associated injuries, and management of traumatic rib fractures. J Chin Med Assoc. 2016;79:329–34. https://doi.org/10.1016/j.jcma.2016.01.006. CrossRefPubMed
Vana PG, Neubauer DC, Luchette FA. Contemporary management of flail chest. Am Surg. 2014;80:527–35. PubMed
Testerman GM. Adverse outcomes in younger rib fracture patients. South Med J. 2006;99:335–9. https://doi.org/10.1097/01.smj.0000203815.29757.d3. CrossRefPubMed
Brasel K, Guse C, Layde P, Weigelt J. Rib fractures: relationship with pneumonia and mortality. Crit Care Med. 2006;34:1642–6. CrossRef
Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138:717–25. https://doi.org/10.1016/j.surg.2005.07.022. CrossRefPubMed
Cannon RM, Smith JW, Franklin GA, Harbrecht BG, Miller FB, Richardson JD. Flail chest injury: are we making any progress? Am Surg. 2012;78:398–402. PubMed
Dehghan N, De Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the national trauma data bank. J Trauma Acute Care Surg. 2014;76:462–8. https://doi.org/10.1097/TA.0000000000000086. CrossRefPubMed
Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003;23:374–8. CrossRef
Clark GC, Schecter WP, Trunkey DD. Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion. J Trauma. 1988;28:298–304. CrossRef
Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma: a practice management guideline from the Eastern Assocaiation for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82:618–26. https://doi.org/10.1097/TA.0000000000001350. CrossRefPubMed
Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB. Rib fracture fixation in the 65 years and older population: a paradigm shift in management strategy at a Level I trauma center. J Trauma Acute Care Surg. 2017;82:524–7. https://doi.org/10.1097/TA.0000000000001330. CrossRefPubMed
Taylor BC, French BG, Fowler TT. Surgical approaches for rib fracture fixation. J Orthop Trauma. 2013;27:e168–73. https://doi.org/10.1097/BOT.0b013e318283fa2d. CrossRefPubMed
Pape HC, Remmers D, Rice J, Evisch M, Krettek C, Tscherne H, et al. Appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making. J Trauma. 2000;49:496–504. CrossRef
Austin PC. An Introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46:399–424. https://doi.org/10.1080/00273171.2011.568786. CrossRefPubMedPubMedCentral
R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2017. http://www.R-project.org/.
Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52:727–32. https://doi.org/10.1097/00005373-200204000-00020. CrossRefPubMed
Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216:924–32. https://doi.org/10.1016/j.jamcollsurg.2012.12.024. CrossRefPubMed
Khandelwal G, Mathur RK, Shukla S, Maheshwari A. A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture. Int J Surg. 2011;9:478–81. https://doi.org/10.1016/j.ijsu.2011.06.003. CrossRefPubMed
Pieracci FM, Lin Y, Rodil M, Synder M, Herbert B, Tran DK, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg. 2016;80:187–94. https://doi.org/10.1097/TA.0000000000000925. CrossRefPubMed
- Rib fixation versus non-operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: a multicenter cohort study
Reinier B. Beks
Mirjam B. de Jong
Rolf H. H. Groenwold
Michael J. R. Edwards
Luke P. H. Leenen
Roderick Marijn Houwert
Jan Paul M. Frölke
- Springer Berlin Heidelberg
European Journal of Trauma and Emergency Surgery
Official Publication of the European Society for Trauma and Emergency Surgery
Print ISSN: 1863-9933
Elektronische ISSN: 1863-9941
Neu im Fachgebiet Orthopädie und Unfallchirurgie
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